Medicare-Approved Drug Benefits in NC – Updates and Reminders



Getting Ready for Medicare D 2009

Reminders to NC Pharmacists

Provided by Senior PharmAssist & The NC Seniors’ Health Insurance Information Program (SHIIP)

See and Consumer/SHIIP/SHIIP.asp for more information.

As you know, we are in the open enrollment period for Medicare Part D until 12/31/08. There are 49 stand-alone Medicare-approved drug plans available in North Carolina. In addition, many of the Medicare Advantage plans also include a drug benefit, and their availability and cost varies by county. Many of the plans have changed their cost-sharing significantly (premiums, deductibles and co-payment or co-insurance amounts) and added more “utilization management tools” (PA, step therapy and quantity limits) for 2009.

▪ The E1 transaction or Eligibility Inquiries – To determine a Medicare beneficiary’s Part D coverage information (any income or age): Your computer software vendor should have an online eligibility verification system. This allows you to enter basic information about a Medicare beneficiary to then find their drug plan data (BIN, PCN, etc.). However, pharmacies have different software and methods for conducting this search. Please speak to your management or software vendors to make sure your staff is ready to use this tool. Also, you can call the Medicare’s pharmacist helpline (1-866-835-7595) with the patient’s name, Medicare ID, DOB, and address – and they should give you the information you need to adjudicate claims.

▪ “POS Facilitated Enrollment”: This process is designed to ensure that “dual eligibles” (individuals who have both Medicare & Medicaid) and others eligible for the Part D low-income subsidy or “extra help” can get their medications filled, even though their enrollment in a Part D plan is not active. First, you should conduct an E1 query or call the CMS pharmacy helpline to determine if s/he is already enrolled in a drug plan. If they are not, you should follow the “P.O.S. Facilitated Enrollment” process with PBM Wellpoint NextRx (BIN – 610575 & PCN CMSDUAL01). See details at -

Again, pharmacy software is different between stores so please check with your management or IT provider. The Wellpoint Next Rx provider help desk for this POS FE process is: 1-800-662-0210 or 1-800-957-5147.

▪ Transition Fill Policies: There is a 90-day time frame in which Part D plans should allow a 30-day temporary fill in outpatient settings if someone is in a new plan (or in some instances when someone is continuing in a plan, but the medication is no longer on formulary or has restrictions). This applies throughout the year and is most critical to remember at the start of each calendar year. This fill should count towards TrOOP (true out-of-pocket) and should be a negotiated rate.

▪ CHANGING PLANS and NCRx: “Dual eligible” Medicare beneficiaries, as well as anyone with “extra help” or the low-income subsidy, have a continuous “special enrollment period,” meaning they can join or switch drug plans at any time (effective the first of the following month). If someone with the full low-income subsidy is paying more than $2.40/generic or $6.00/brand for covered medications in 2009, then they likely need to switch plans or appeal for coverage. Any person who qualifies for his or her state’s SPAP (State Pharmacy Assistance Program) has one “special enrollment period” outside of the annual election period (11/15 – 12/31) to join or switch drug plans. NCRx is NC’s SPAP for Medicare beneficiaries 65 and older, and the premium assistance will be up to $29/month for 2009. Call 1-888-488-6279 or for more information as they do not contract with all Part D plans. NC SHIIP (Seniors’ Health Insurance Information Program – 1-800-443-9354), local SHIIP coordinators, Medicare (1-800-Medicare) and others – depending on your county – can help Medicare beneficiaries compare Part D plans using the CMS drug plan finder tool at .

▪ Medicare Advantage Plans: In addition to the 49 stand-alone drug plans, there are dozens of Medicare Advantage plans, some of which also include drug benefits. Many Medicare beneficiaries are confused by these plans and how the benefits differ from traditional Medicare. Please refer these questions to NC SHIIP (1-800-443-9354) or your local SHIIP coordinators.

▪ Late Enrollment Penalties: The late enrollment penalty for people who have not had “creditable” coverage since Medicare drug benefits began in 2006, though they were eligible, will not be reflected on the CMS/Medicare website. It is based on 1% per month of the 2009 national base premium ($30.36). As an example, if they were eligible for Part D in June 2006 (31 months from Jan. 2009), they will owe $9.41 per month more than had they signed up in June 2006. People who are dual eligible or have qualified for the LIS program are not subject to the late enrollment penalty.

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